Since Louisiana expanded Medicaid in 2016, an additional 502,647 newly eligible adults enrolled in the state’s health care program for low-income residents. In Louisiana, a state that has historically faced challenges related to overall health status and health disparities, this expansion of coverage opens new doors for improving health outcomes. Medicaid covers nearly a third of Louisiana’s population, providing the agency with a unique opportunity to impact the health status of the entire state, particularly individuals who were not accessing health services prior to expansion. For Jen Steele, Louisiana’s Medicaid director, maximizing Medicaid’s opportunities to improve health outcomes and reduce health disparities is a critical motivator behind her work.

Q: Louisiana has faced significant challenges related to overall health outcomes. How would you describe the situation your state faces in improving health outcomes overall?

The good news is we have tremendous opportunity for improvement, but to get the momentum needed to improve these rankings is a real challenge.

A: The biggest challenge is where we are starting from. We vie for either 49th or 50th in overall state health rankings every year. This year we are 50th, last year we were 49th. When you start from the base of poverty and add the challenges in education and employment opportunities that exist in Louisiana, combined with social inequalities that overburden certain and/or historically vulnerable populations with health inequities, it is hard to overcome where we stand.

The good news is we have tremendous opportunity for improvement, but to get the momentum needed to improve these rankings is a real challenge. For example, we recently worked with America’s Health Rankings to identify what it would take to improve Louisiana’s rankings. We looked back at 2016, and the statistical gains we would need to surpass not just Mississippi, but also Arkansas (which was ranked 48th), were overwhelming. Focusing on key drivers of our low ranking, Louisiana would have to concurrently: (1) reduce the prevalence of low birth weight to the national average (from 10.5 percent to 8.0 percent); (2) reduce the infant mortality rate to the national average (from 8.1 to 5.8 per 1,000); and (3) reduce preventable hospitalizations to the national average (from 67.5 to 49.5 per 1,000 beneficiaries).

Q: Health equity is increasingly at the center of policy discussions, particularly as it relates to individuals enrolled in Medicaid. What does health equity mean to you and your state?

A: We are increasingly focused on issues of health equity. Whether you are talking about race, gender, or geography, the statistics are not the same for all. In our current managed care procurement, we pay a lot of attention to population health, health inequity issues, and social determinants of health. We recognize the important role that health equity plays in health outcomes.

It is not just the Medicaid agency that has been focusing on health equity, the entire Louisiana Department of Health under the leadership of Dr. Rebekah Gee is engaged. In fact, we just created a section at the Department that is focused on (among other health equity and disparities efforts) developing an agency-wide health equity plan to inform how we prioritize, organize, and implement programmatic changes that people feel externally.

Q: It can take many years for data to reflect investments in reducing health disparities and show improvement in overall state health outcomes. How do you measure success for these efforts long-term? How do you track progress in the short-run?

A: Our Healthy Louisiana dashboard is a good example of how we have tried to do this. When we first expanded Medicaid, we used the dashboard to report on enrollment. Later, as claims data became available, we started reporting on access to care. We knew a common criticism of Medicaid is that coverage does not equal access to care, so using this dashboard we are able to demonstrate how many people are now getting breast cancer screenings, colonoscopies, and polyps removed as well as how many are avoiding colon cancer. We identify people who are newly diagnosed with hypertension or diabetes, who are going to a primary care physician for the first time, and who are using behavioral health services. We believe that access to preventive and primary care will change outcomes. Given the timing of the data that drives state health rankings, however, it will take years to see the statistical outcomes from these inputs.

Q: There are many policy and operational levers states can use to address health outcomes. Which have you found to be most important?

A: We have focused primarily on payment levers. First, we streamlined our quality measures set. When we initially examined our measures in 2016, there was no uniformity across our five health plans. Out of 74 measures incentivized by our health plans, not one was incentivized across all five, so you can imagine the market confusion that created. So, we intentionally streamlined and standardized the set, establishing 16 clinical quality measures linked to payment incentives across all five plans. Second, we added a two percent withhold of capitation payments to our health plan contracts as an incentive for meeting quality measures and value-based payment use targets. Now, we are spending more time focusing on what we cover and how. We are working with the Oregon Health and Science University and its Medicaid Evidence-based Decisions Project to develop a process for reviewing our covered services policies and identifying policy changes using an evidenced-based approach. We are also looking at tools like Choosing Wisely and the Health Waste Calculator to identify areas where we are not making the best use of our dollars to achieve targeted health improvement outcomes.

Q: What role do you see staff capacity and skills playing in relation to the policy levers you can push on?

We have worked hard over the past few years to get the right leadership. We have a medical director who is focusing heavily on [making] sure that people are getting the right care at the right time. We have another clinical leader who is focused on our health equity work.

A: In order to identify and influence policy levers to enhance care, you need people who are good at data, who are good at stakeholder engagement, who understand the social determinants of health that affect the health of Medicaid enrollees and how to leverage this information in the care dynamic, and who are good at clinical leadership. We have worked hard over the past few years to get the right leadership. We have a medical director who is focusing heavily on clinical covered services policies and clinical criteria for utilization management to make sure that people are getting the right care at the right time. We have another clinical leader who is focused on our health equity work. Recently, these two clinical leaders have been traveling throughout the state holding public forums to get input on what quality measures should be included in our next generation managed care organization contracts. We recognize that it is important to ensure buy-in among clinicians across the state to help us achieve our goals.

Q: Medicaid is not solely responsible for or capable of improving overall health outcomes. Partnerships with other stakeholders within state government and in the community are therefore essential to your efforts. What have you learned about how to work effectively with these partners?

A: We are working increasingly with the Office of Public Health (OPH) as we expand our emphasis on population health and health equity. Our hepatitis C subscription payment model is a good example. We have a Solicitation for Offers, or SFO, out to contract with at least one manufacturer of curative hepatitis C drugs so we can move to eliminate hepatitis C as a public health problem in Louisiana by getting unrestricted access to these drugs to treat as many people as possible. Just last week, we received three responses to the SFO. Later this year, our plan will be in place. OPH is providing the expertise of the public health community to address disease surveillance and registries, identify impacted populations along with their social determinants of health, and conduct outreach. That approach is typically not the Medicaid approach, but it is necessary when you are trying to have a deep impact like hepatitis C eradication in a state. This model is not limited to Medicaid, but is also targeted to the corrections population that has some of the highest prevalence rates of hepatitis C. When we were preparing for Medicaid expansion, we collaborated with our state Department of Corrections through a data exchange project to prepare for pre-release enrollment for the justice-involved population so that the state could ensure their continuity of care. Now, as we bridge into this work with public health, the work we had originally done to build that relationship with corrections has proved to be really instrumental.

Q: What advice or lessons would you share with other Medicaid leaders who are looking to improve health outcomes?

It is great to learn about what is going on nationally, but you need to have a solid handle on what is going on in your state and have engaged dialogue with people locally about the different ideas that are out there and what makes sense for your state.

A: First and foremost, actively engage your stakeholders while also identifying and leveraging social determinant of health factors and approaches that can inform one’s care dynamic. I would encourage folks not to just stay inside the agency, read the latest health policy news, and come up with ideas from other states and try to move forward with them. It is great to learn about what is going on nationally, but you need to have a solid handle on what is going on in your state and have engaged dialogue with people locally about the different ideas that are out there and what makes sense for your state. There is no such thing as “plug and play” from another location and there is danger in attempting to do that. Particularly in a state like Louisiana, you really have to pause and think about where we are starting from. Something we are very sensitive to is how to leverage ideas from other places in a way that is accessible without making such a large leap, and that really helps maintain your credibility and ability to move ideas forward with people locally.